In-depth: 'Lazarus Drug': ARVs in the treatment era

AFRICA: The treatment era: A global overview

The number of people receiving ARVs in developing countries has more than doubled from 400,000 in December 2003 to about 1 million in June 2005, according to a report released by the World Health Organization (WHO) and UNAIDS

JOHANNESBURG, 30 August 2005 (IRIN) - As a result of falling antiretroviral (ARV) prices, new sources of international funding and growing political commitment, providing treatment to HIV-positive people in the developing world is, for the first time, becoming an achievable goal.

The number of people receiving ARVs in developing countries has more than doubled from 400,000 in December 2003 to about 1 million in June 2005, according to a report released by the World Health Organization (WHO) and UNAIDS.

However, access to HIV treatment still falls short of the growing need, and overall progress is unlikely to be fast enough to reach the target, set by WHO and UNAIDS, of treating three million people by the end of 2005 in the '3 x 5' programme.

This comes at a time when the HIV/AIDS epidemic is still outpacing the global response, making the need to expand access to ARVs critical. Globally, an estimated 30 million people have already died of AIDS and today an estimated 40 million people in the developing world are HIV positive.

Speaking in June 2005 at the release of a special United Nations report on AIDS, UN Secretary-General Kofi Annan called for urgent action, saying, "How we fare in the fight against AIDS is crucial: halting the spread is not only a Millennium Development Goal in itself; it is a prerequisite for reaching most of the others".

In sub-Saharan Africa 3.8 million people need treatment, but as of June 2005, only 500,000 people were on the life-prolonging medication.

The number of people currently receiving ARVs in Asia tripled to 155,000 between June 2004 and June 2005. Asia - the second most affected region in the world - is facing soaring HIV/AIDS rates, with India soon to overtake South Africa as having the highest number of infections by 2006.

Epidemiologists also predict that in China 10 to 15 million people will be infected by 2010, according to the US-based National Intelligence Council Report of late 2002.

UNAIDS estimates that 8.2 million people in Asia are living with the virus. Of these, 1.3 million need ARVs but, in most cases, countries administer treatment to less than 25 percent of those who need it, according to TREAT Asia, an organisation with monitoring and treatment sites in 24 locations across the region.

Complex environment

Often referred to as the 'Lazarus drug', the potential of ARVs to dramatically improve the health and quality of life of those near death, while extending the lives of people with HIV/AIDS, is now well recognised.

But the global rollout of ARVs takes place in a complex social, political and economic environment.

Dr Douglas Webb of the UN Children Fund's (UNICEF) Africa HIV/AIDS section told IRIN: "Investment in ARV prophylaxis will save costs in AIDS-related treatment, as well as countless lives. The most expensive, and needless, scenario is to allow people to develop full-blown AIDS."

Millions of dollars spent now could save billions in the future. WHO data from Brazil indicates that the costs associated with providing universal access to ARV therapy from 1996 to 2002 amounted to US $1.8 billion, but the savings in hospital and ambulatory care services reached $2.2 billion, "not to mention the broader savings related to teachers who keep on teaching, parents who remain with their children, and farmers who continue to work on their land."

Webb described Brazil as a "shining light leading the way forward" in terms of the government's handling of ARV treatment and offering universal access to the people.

Brazil has also proven that it is possible to contain HIV/AIDS in a resource-poor environment with relatively weak health infrastructure. It has delivered free ARVs to virtually every HIV-positive patient in need - despite the size of the country and its large population.

Profits and prices

Most of the debate concerning the availability and access to antiretroviral therapy (ART), now revolves around the core issues of economics, equity and ethics.

A mix of payment systems - free, subsidised or self-paying - are applied by governments, and criteria for access to ART differ widely. What is increasingly clear, however, is the inequity in access, even when the drugs are free.

"Given their limited access to income and other productive resources, women are less likely to be able to participate in self-pay schemes, even with subsidised prices," a report by the US-based Centre for Health and Gender Equity noted.

Because of the additional cost of paediatric ARVs, and the difficulty of calculating the correct dose when using adult ARVs, HIV-positive children are another group that are often sidelined by the existing rollout.

A study in Senegal found that when the cost of drugs for opportunistic infections, laboratory exams, consultations and hospitalisation fees were calculated, patients on ART paid an additional US $130 a year - a significant amount for most people living on less than a dollar a day, and a reason cited for treatment interruptions.

The "Freeby5" campaign argues that any form of payment disadvantages the poor, while exemption systems are not cost-effective. The signatories to the declaration noted that a "prerequisite for ensuring that treatment programmes are scaled up, equitable and efficient, and provide quality care, is to implement universally free access to a minimum medical package, including ARVs, through the public healthcare system".

The unfortunate reality is that not everybody who needs treatment will be able to access it - but if you are rich and live in a city, you stand a better chance. "What we can look forward to is some treatment, for some people, in some settings," said professor Alan Whiteside at the Health Economics and HIV/AIDS Research Division of the University of KwaZulu-Natal, South Africa.

He called for an informed debate at national and community level about who should have access to treatment, rather than leaving it to the doctors or the ad hoc rationing caused by limited services.

The well-resourced and powerful pharmaceutical companies have lobbied hard to protect their patents or intellectual property rights and maintain higher prices for their drugs, while activists have encouraged countries to stimulate cost-cutting competition and patent-breaking manufacture of the medication.

Nevertheless, international pressure has led to major drug companies cutting their prices significantly in recent years.

The actual price of ARV drugs is not the most important issue to UNICEF's Dr Doug Webb. "It's never really been about the prices: the demand for ARVs is dependant on the infrastructure to deliver. There are all kinds of blockages in the delivery systems, and with over 80 percent of those infected not knowing their own status you don't have a demand-driven economic context."

The doctor gap

The delivery platform for national rollout programmes is the overburdened and under-resourced public health system, whose decline has been accelerated by the toll of HIV/AIDS.

WHO acknowledges that "major new investment in countries' health systems" will be needed - an additional 100,000 health and community workers for a start. It estimates that the cost of achieving the '3 by 5' goals will be US $5.5 billion, but points to the ongoing mobilisation of international finance, and the lasting benefits that well-managed increased spending on ART will have on public healthcare in general.

Numerous agencies across Asia also report the same problem in areas where generic ARV products are widely available, but where the 'doctor-gap'- as TREAT Asia describes it - is acute.

In India just 510 doctors know how to administer ARVs, meaning that the potential doctor-to-HIV-patient ratio for ARV therapy would be over 9,000 patients to a single doctor. Experts in China estimate there are only 200 doctors trained to administer ARV therapy to a rapidly growing population of 840,000 HIV-positive individuals.

Continued stigma and denial

Where ART is available, agencies are finding it hard to convince people to come forward to take the medication, as stigma still influences people's response to treatment.

Denial is the preferred option for many who know they are living with HIV, even if they have sufficient funds or free access to ARV treatment. Experts estimate that in some regions 80 percent to 90 percent of those infected are unaware of their status.

In its extensive work in providing ARV treatment in Latin America, Africa and Asia, Medecins Sans Frontieres (MSF) have found that the importance of working at the community level to overcome social stigma and ensure adherence to the ARV regime is critical if the therapy is to be successful. In their Bangkok policy document of July 2004, MSF emphasised that community participation was equally as important as reducing the cost of the medication if ARV treatment is to be scaled up.

Beyond the issues of social stigma and limited medical capacity, experts cite a wide range of economic and political forces that affect access to treatment in most developing countries, such as trade rules that interfere with generic competition and prevent millions of poor people from accessing ARV medication by putting it beyond their economic reach.

With just four months to go before the end of the year, it seems unlikely that the WHO campaign to put three million people in the developing world on anti-AIDS drugs by the end of 2005 will be met.

"Treatment expansion is moving at a snail's pace," reported MSF in late January 2005. "From the perspective of a medical humanitarian organisation, working in resource-poor countries to treat people with AIDS, the global picture is bleak."

According to MSF, only 700,000 or 12 percent of the nearly six million people in need of ARVs are currently receiving the drugs.

"We have to be optimistic - but its going to take a lot longer than we expected," Dr Douglas Webb told IRIN while commenting on the failure to meet the '3 x 5' ARV treatment targets. "We need to massively invest in public delivery systems, combined with a huge increase in uptake of voluntary counselling and testing."